RESEARCH ARTICLE
Incidence, Time Course and Predictors of Impairments
Relating to Caring for the Profoundly Affected arm After
Stroke: A Systematic Review
Rhoda Allison1*, Laura Shenton1, Kathryn Bamforth1, Cherry Kilbride3 & David Richards2
1
Stroke Service, Newton Abbot Hospital, Torbay and Southern Devon Health and Care Trust, Newton Abbot, UK
2
Mood Disorders Centre, College of Life and Environmental Sciences, University of Exeter, Exeter, UK
3
Brunel University London, Centre for Research in Rehabilitation, London, UK
Abstract
Background and purpose. A significant number of stroke survivors will not recover the use of their affected arm. A
proportion will experience pain, stiffness and difficulty with basic care activities. The purpose of the review was to
identify predictors of difficulty caring for the profoundly affected arm and establish the incidence and time-course
of the related impairments of pain, spasticity and contracture. Method. Data sources: Databases (PubMED,
MEDLINE, AMED, EMBASE, CINAHL and the Cochrane Controlled Trials Register) were searched from inception
to December 2013. Additional studies were identified from citation tracking. Review methods: Independent reviewers
used pre-defined criteria to identify eligible studies. Quality assessment and risk of bias were assessed using the
McMasters Assessment Tool. A narrative evidence synthesis was performed. Results. Thirty-nine articles reporting
34 studies were included. No studies formally measured difficulty caring for the arm, but related impairments were
common. Incidence of spasticity in those with weakness ranged from 33% to 78%, shoulder pain affected 22% to
90% and contracture was present in at least 50%. Spasticity and pain appear within 1 week of stroke, and contracture
within two weeks. Impairments continued to develop over at least 3–6 months. The most frequent predictors of
spasticity and contracture were weakness and reduced motor control, and the risk of pain is most commonly predicted
by reduced sensation, shoulder subluxation, weakness and stroke severity. Discussion. There is no published evidence
on predicting the likelihood of difficulty caring for the arm following stroke. However, the related impairments of
spasticity, pain and contracture are common. Given the time-course of development, clinicians may need not only
to intervene early but also be prepared to act over a longer time period. Further research is needed to examine difficulty
caring for the arm and the relationship with associated impairments to enable researchers and clinicians to develop
targeted interventions. © 2015 The Authors Physiotheraphy Research International Published by John Wiley & Sons Ltd.
Received 12 May 2014; Revised 27 October 2014; Accepted 13 April 2015
Keywords
disability; pain; stroke; spasticity
*Correspondence
Rhoda Allison, Stroke Unit, Newton Abbot Hospital, Newton Abbot, Devon, TQ12 2SL, UK.
E-mail: [email protected]
Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/pri.1634
Introduction
Stroke is the second largest cause of death in adults and
the principal cause of long-term severe adult disability
worldwide (Lopez and Mathers, 2006; American Heart
Association, 2009; Department of Health, 2009). Seventy
per cent of people with stroke will experience arm
Physiother. Res. Int. (2015) © 2015 The Authors Physiotheraphy Research International Published by John Wiley & Sons Ltd.
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
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R. Allison et al.
The Profoundly Affected Arm After Stroke
weakness, and 62% of these will not recovery dexterity
in the arm at 6 months post-stroke (Kwakkel et al.,
2003). For the purposes of this review, the term ‘profoundly affected arm’ is used to describe the situation
where a stroke survivor has no movement in the affected arm or when movement is not functionally useful. This term was developed in consultation with a
group of stroke survivors.
Current physical therapies in stroke rehabilitation
are based predominantly on exercise and task-specific
training (Duncan et al., 2005; Intercollegiate Stroke
Working Party, 2012). However, most interventions
aimed at improving active function require the presence of some movement within the arm initially, and
research has shown that additional physiotherapy and
practice of motor tasks do not improve active function
in those with most significant arm weakness (Parry
et al., 1999). For those unlikely to regain active function, a different approach focused on managing disability and avoiding complications in the arm is
required. Managing disability involves assessing and
reducing impairments in the arm, which can impact
negatively on the ability to care for the arm including
tasks such as hand washing, nail cutting and dressing
(passive function activities) (Sheean, 2001). Impairments, which are commonly associated with the profoundly affected arm and are often targeted for
treatment in order to reduce difficulty caring for the
arm, include spasticity (Bhakta et al., 2000), contracture (De Jong et al., 2006, 2006) and pain (Shaw
et al., 2010). People with arm spasticity and contracture may develop abnormal limb posturing, which
can make washing of the axilla, elbow crease and hand
difficult, leading to hygiene problems, and potential
skin breakdown (Mayer et al., 1997; Fergusson et al.,
2007) and increased carer burden (Katalinic et al.,
2010). Equally, pain is also often a focus of treatment
in improving care of the arm (Ashford and TurnerStokes, 2009). It is possible that other impairments
may impact on passive function of the arm, but there
is currently little evidence to support a positive relationship between complications in the arm and impairments such as joint subluxation (Kumar and
Swinkels, 2009), and it is difficult to assess the impact
of sensory changes in isolation from motor problems
(Intercollegiate Stroke Working Party, 2012).
Management of the profoundly affected arm is a
complex intervention, which has traditionally included
techniques such as splinting (Lannin et al., 2007),
positioning (De Jong et al., 2006), stretching
(Bovend’Eerdt et al., 2008) and the use of medications
such as botulinum toxin (Bhakta et al., 2000). However, evidence to support these interventions is mixed,
and frequently, trials have been designed without
considering the natural course of impairments and
disability in this condition. For example, in a study of
splinting to prevent contracture (Lannin et al., 2007),
the intervention was provided within the first 8 weeks
of stroke for a period of 4 weeks, but there was no rationale to suggest if these timings reflect the period
where risk of contracture is greatest (Manigandan and
Charles, 2007). Currently, little is known about which
people with a profoundly affected arm are most at risk
of developing associated impairments or difficulty with
passive function. This systematic review has two aims.
Firstly, to identify the incidence and natural course of
pain, spasticity, contracture and difficulty with passive
care in the profoundly affected arm. Secondly, to identify potential predictors that could be used in routine
clinical settings in the early stages of post-stroke care
to identify those most at risk of difficulty caring for
the arm or these related impairments. This is important, as more knowledge of how the profoundly affected arm changes over time will assist researchers
and clinicians in designing and evaluating appropriately timed and targeted interventions to ultimately
benefit the stroke survivor and their carers.
Methods
Search strategy
The following databases were systematically searched:
PubMED, MEDLINE, EMBASE, CINAHL, AMED
and the Cochrane Library, from the inception date of
each database up to December 2013. The search terms
are given in Appendix 1. In addition, citation tracking
of journals was undertaken.
Criteria for inclusion of studies
The review included published research articles that
fulfilled the following PICOS (Liberati et al., 2009)
criteria:
Participants: adults (over 18 years of age) with arm
weakness post-stroke
Interventions: the review was not designed to evaluate a
specific intervention but did not exclude reports of data
Physiother. Res. Int. (2015) © 2015 The Authors Physiotheraphy Research International Published by John Wiley & Sons Ltd.
R. Allison et al.
from intervention studies that provided data to answer
the review questions (for example, data from control
groups identifying changes over time)
Comparators: not applicable
Outcomes: ease or difficulty of passive function of the
arm, pain, spasticity or contracture.
Study design: (1) Observational studies of the natural
course of events post-stroke and (2) studies evaluating
the ability of identified factors (either demographic factors or impairments related to post-stroke presentation) that were assessed within the first 8 weeks of
stroke to predict pain, impairment and capacity to care
for the arm after stroke.
Studies were excluded if they were not available in
English, targeted children or if purely laboratory-based
tests such as medical imaging used as predictors. Case
series and case reports were excluded owing to the high
potential for bias in these study designs. Studies that
considered recovery of active function in the arm only
were also omitted.
Study selection
Initially, titles, then abstracts, were screened by two
members of the review team, working independently.
Full studies that met the inclusion criteria were obtained for more detailed evaluation.
Data extraction, management and
assessment of potential risk of bias
Two reviewers, working independently, undertook the
data extraction and identification of risk of bias, using
structured formats. Key data extraction included the
following items: general study information (title,
author and country of study); study design and characteristics (participant characteristics, potential predictors and outcomes); and findings including length of
follow-up. Agreement between reviewers was calculated using kappa scores, and any differences in data
extraction were resolved by mutual agreement, and
where necessary, referred to a third person. Quality assessment and risk of bias in the selected studies were
appraised using a tool adapted from the Quality Assessment Tool for quantitative studies developed by the Effective Public Health Practice Project at McMaster’s
University in Canada (Effective Public Health Practice
Project, 2008).
The Profoundly Affected Arm After Stroke
Summary measures and synthesis of
results
The principle summary measures were incidence of
each impairment and risk ratio for predictors of either
impairment or difficulty with passive care (when this
was reported). Data were narratively synthesized via a
series of summary tables and reported incidence,
change over time and results of any evaluation of predictors. Meta-analysis was not indicated because of inherent heterogeneity of the studies.
Results
Study selection
A total of 539 references were initially identified. There
were 219 duplicate references. Figure 1 summarizes the
search and reasons for exclusion. Fifty-eight full articles
were retrieved, but a further 19 were excluded because
they focused on only active rather than passive function, did not include the arm, evaluated laboratorybased tests or imaging or included people with arm
weakness for other reasons than stroke. In total, 39
publications were suitable for quality assessment. Five
pairs of articles (Table 2) presented differing data from
the same studies, but to prevent double reporting, this
review includes 39 publications, describing 34 different
studies.
Study characteristics
Participants
The characteristics of study participants are summarized in Table 1. Overall a total of 20,590 patients participated in the studies. None of the studies specifically
targeted people with a profoundly affected arm.
Broadly, they focused on either general populations of
people recovering from stroke (including those with a
weak arm) or targeted specific populations including
people with stroke and hemiplegia, weakness or those
who needed rehabilitation. Five studies limited recruitment to people who had sustained ischaemic stroke
only, but the others did not differentiate between people with sub-types of stroke. One study explicitly included people with more severe stroke moving to care
homes (Sackley et al., 2008). Six studies were from
the UK, 11 from Europe, 3 from North America and
14 from other countries. One study involved participants in 35 different countries (O’Donnell et al.,
Physiother. Res. Int. (2015) © 2015 The Authors Physiotheraphy Research International Published by John Wiley & Sons Ltd.
R. Allison et al.
The Profoundly Affected Arm After Stroke
Figure 1. Search results
2013). The average age of study participants was
65.5 years, and they were recruited at any point between the onset of stroke and 1 year after.
therapy (O’Donnell et al., 2013). Two publications presented data from studies of the predictive value of motor evoked potentials (van Kuijk et al., 2007) and
transcranial magnetic stimulation (De Jong et al., 2011).
Interventions/comparators
The search did not specifically target studies that had
evaluated a specific intervention. However, six of the articles included reported data that had been collected as
part of larger studies designed to evaluate interventions.
Two studies presented data from control groups of intervention trials (Pandyan et al., 2003; Malhotra et al.,
2011), one study presented data from both arms of a
trial comparing day hospital and community-based
therapies (Wanklyn et al., 1996) and one study presented data from all cohorts in a study of antiplatelet
Outcomes
Table 2 summarizes outcomes measures and predictor
variables used in the studies. Three of the studies briefly
referred to the ease or difficulty with passive care of the
arm (Lundstrom et al., 2008; Kong et al., 2010;
Lundström et al., 2010). However, none of these studies measured this as an outcome in a systematic way, although increasingly, measures of difficulty with passive
care of the arm are being developed (Bhakta et al.,
2000). Fourteen of the publications examined spasticity
Physiother. Res. Int. (2015) © 2015 The Authors Physiotheraphy Research International Published by John Wiley & Sons Ltd.
123
152
148
214
165
106
327
58 (subset)
Taiwan
The Netherlands
UK
Iran
Singapore
Singapore
Holland
Thailand
Australia
UK
Sweden
Cheng et al., 1995
De Jong et al., 2011
Gamble et al. 2002
Gamble et al., 2000
Hadianfard and
Hadianfard, 2008
Kong et al., 2012
Kong et al., 2010
van Kujik et al., 2007
Kuptniratsaikul et al., 2013
Kwah et al., 2012
Leathley et al., 2004
Watkins et al., 2002
Lindgren et al., 2007
Lindgren et al., 2012
Physiother. Res. Int. (2015) © 2015 The Authors Physiotheraphy Research International Published by John Wiley & Sons Ltd.
30
UK
Brazil
35 countries
Moura et al. 2009
O’Donnell et al., 2013
146
15754
140
Sweden
Lundstrom et al., 2009
Lundstrom et al., 2008
Malhotra et al., 2011
47
Sweden
Lundstrom et al., 2010
40
140
50
50
30
United States
Bohannon, 1988
253
18
85
Sweden
Australia
Turkey
Sample
size
Appelros, 2006
Ada et al., 2006
Aras et al., 2004
Setting
Table 1. Characteristics of participants and studies
People with first stroke and no function
of arm
People with ischaemic stroke
People with first ever stroke
People with first ever stroke, with motor
or sensory deficit and pain
People with first ever stroke and initial
weakness
People with first stroke
People with stroke, with weakness and
receiving rehabilitation
People with stroke, with weakness and
receiving rehabilitation
People with ischaemic stroke, with
complete arm paralysis
People with stroke
People with stroke
People with stroke
People with stroke
People with first-ever stroke
People with stroke, with hemiplegia
People with hemiplegia and receiving
rehabilitation
People with stroke, with hemiplegia and
receiving rehabilitation
People with stroke, receiving inpatient
rehabilitation
People with first ischaemic stroke with
arm weakness, receiving TMS
People with stroke
Targeted
population
Fixed: onset
Variable: (median 15)
Variable: 21 (range 7–35)
Fixed: 12 months
Variable: 2–10 days
Fixed: onset
Variable: (median 24)
Variable: up to 28 days
Fixed: onset
Fixed: onset
Variable: 15 (SD 14.6)
Variable: not reported
Variable: 0–60
Fixed: 14
64 (25–88)
65 (not reported)
70 (52–90)
71 (SD 13)
74 (34–84)
73 (17–102)
71
62 (59–75)
78 (IQR 65–84)
70 (SD 11.3)
68 (59–77)
61 (SD 13.3)
63 (53–76)
61 (40–75)
70.6 (29–93)
70.3 (58–82)
62 (40–79)
Variable: 21–180
Variable: within 48 hours
68 (SD 10.6)
74 (33–95)
63 (36–82)
59.5 (47–70)
Average age at
recruitment (years)
Variable: 31 (SD 15)
Fixed: onset
Variable: 17 (14–28)
Variable: not stated
Time since stroke at
recruitment (days)
Spasticity-general
Pain-general
Pain-general
Spasticity-arm
Contracture-wrist
Spasticity-arm or leg
Pain-shoulder
Spasticity-general
Contracture-general
Spasticity-general
Spasticity-arm
Spasticity-arm
Spasticity-arm
Pain-shoulder
Pain-shoulder
Spasticity-elbow
Pain-shoulder
Pain-shoulder
Pain-general
Contracture-elbow
Pain-shoulder
Impairment
studied
(Continues)
Longitudinal
Longitudinal
Cross
sectional
Longitudinal
Longitudinal
Longitudinal
Longitudinal
Longitudinal
Longitudinal
Longitudinal
Longitudinal
Longitudinal
Longitudinal
Longitudinal
Longitudinal
Cross-sectional
Longitudinal
Longitudinal
Longitudinal
Cross-sectional
Design
R. Allison et al.
The Profoundly Affected Arm After Stroke
95
66 (subset)
327
211
Taiwan
Canada
Singapore
New Zealand
The Netherlands
UK
Sweden
Thailand
Germany
UK
United States
Pong et al., 2012
Poulin de Courval et al., 1990
Rajaratnam et al., 2007
Ratnasabapathy et al., 2003
Roosink et al., 2011
Sackley et al. 2008
Sommerfeld et al., 2004
Sommerfeld and
Welmer, 2012
Suethanapornkul and
Kuptniratsaikul, 2008
Urban et al., 2010
Wanklyn et al., 1996
Zorowitz et al. 1996
SD = Standard deviation; TMD = Transcranial magnetic stimulation.
20
108
73
135
1201
31
76
94
72
Italy
Picelli et al., 2013
22
107
Sample
size
UK
Italy
Setting
Pandyan et al., 2003
Paci et al., 2007
Table 1. (Continued)
People with stroke, with ongoing
disability returning home
People with stroke presenting with
shoulder subluxation
People with stroke who could sit out of
bed for 30 minutes
People with first stroke, with weakness
People with first ever stroke
People with first ischaemic stroke, with
hemiplegia and receiving rehabilitation
but not receiving medications for
spasticity
People with first stroke, with hemiplegia
People with stroke, with hemiplegia and
receiving rehabilitation
People with unilateral stroke
People with first ever stroke
People with first ever stroke, with
sensory or motor signs
People with Barthel score of <10 at
3 months post-stroke
People with non-severe ischaemic
stroke, over 50 years
People with first stroke and hemiplegia
receiving rehabilitation
People with stroke, with weakness
Targeted
population
Variable: 13–40
Variable: not reported
Variable: not reported
Variable: 84
Fixed: onset
Fixed: 3 months
Variable: 2–14
Variable: 0–14
Fixed: 2 weeks
Variable: not reported
Variable: 21–35
Variable: within 7 days
Variable: 14–28
Variable: 7–27 days
Time since stroke at
recruitment (days)
63 (42–83)
Not reported
68 (59–78)
62 (50–74)
78 (SD 9.5)
76 (31–98)
64 (SD 10.8)
Not reported
67 (52–82)
59 (SD 13)
Not reported
71 (SD 10)
65 (40–93)
72 (62–82)
Average age at
recruitment (years)
Pain-shoulder
Spasticity-general
Spasticity-arm
Pain- shoulder
Cross sectional
Longitudinal
Longitudinal
Longitudinal
Longitudinal
Contracture-general
Pain-general
Spasticity-general
Pain-shoulder
Longitudinal
Cross sectional
Longitudinal
Longitudinal
Longitudinal
Cross-sectional
Longitudinal
Longitudinal
Longitudinal
Design
Pain-shoulder
Pain-shoulder
Pain-shoulder
Pain-shoulder
Pain-shoulder
Pain-shoulder
Contracture-wrist
Spasticity- wrist
Spasticity-arm
Pain-shoulder
Impairment
studied
The Profoundly Affected Arm After Stroke
R. Allison et al.
Physiother. Res. Int. (2015) © 2015 The Authors Physiotheraphy Research International Published by John Wiley & Sons Ltd.
R. Allison et al.
The Profoundly Affected Arm After Stroke
Table 2. Outcomes and predictor measures used in the studies
Outcome measures
Predictors of impairment which were assessed
Pain
De Jong et al., 2011
Kong et al., 2012
MAS (elbow flexors)
AS (shoulder, elbow, wrist
and fingers)
Kong et al., 2010
Kuptniratsaikul et al., 2013
Leathley et al., 2004
AS (shoulder, elbow, wrist
and fingers)
MAS (elbow and knee)
Tone assessment scale
Watkins et al., 2002
MAS (wrist, elbow)
Lundstrom et al., 2010
Global function (mRS)
MAS (shoulder, elbow,
wrist, fingers, hip, knee and
ankle)
MAS (all arm and leg joints)
MAS (unclear which joint
assessed)
MAS (wrist)
MAS (shoulder, elbow, wrist
and fingers)
MAS (all arm and leg joints)
MAS (all arm and leg joints)
AS (elbow and wrist)
Lundstrom et al., 2008
Moura et al. 2009
Pandyan et al., 2003
Picelli et al., 2013
Sommerfeld et al., 2004
Urban et al., 2010
Van Kujik et al., 2007
Pain
Appelros, 2006
Lundstrom et al., 2009
Sommerfeld and
Welmer, 2012
Aras et al., 2004
Bohannon 1988
Cheng et al., 1995
Gamble et al. 2002
Gamble et al., 2000
Hadianfard and
Hadianfard, 2008
Pain-open question at
assessment
Pain-VAS
Pain-interview
Pain-MAND
Pain-reported during
examination
Pain-MAND
Pain-VAS
Pain-VAS
Motor control (FMMA)
Stroke severity (NIHSS)
Global function (mod
BI)
Weakness (UEMI)
Global function (BI)
Weakness (3-point
scale)
Gender
Diabetes
Sensation (MAND)
NA
NA
Higher cortical
dysfunction
(aphasia, confusion or
inattention)
Stroke severity (NIHSS)
NA
Weakness (MST)
Pain (any report)
Arm function (ARAT)
Motor control (items of
European Stroke Scale)
NA
Sensation (LT-MAND)
Arm control (FMMA)
Apraxia (clinical
observation)
Stroke severity (NIHSS)
None
Sensation light touch
(perceiving touch with
cotton wool)
NA
NA
NA
Mood (HADS)
Weakness (ssNIHSS)
Global function (Kenny)
Motivation (MAND)
Kuptniratsaikul et al., 2013
Lindgren et al., 2012
Pain-MAND
Pain-VAS
Sensation (NSAS and LT)
NA
Side of hemiplegia
Lindgren et al., 2007
Pain-VAS
Side of hemiplegia
O’Donnell et al., 2013
Pain-self report;
Stroke severity (NIHSS)
Side of stroke
Premorbid function
(mRS)
Weakness (ssNIHSS)
Sensation (ssNIHSS)
Gender
Age
Weakness (BMRC)
Global function (BI)
Inattention (MAND)
Sensation (LT & FTT)
Sensation (ss NIHSS)
Motor function (ss
NIHSS)
Motor control (BL)
Spasticity (MAS)
Global function (BI)
Proprioception (FTT)
Sensation (LT)
Global function (BI)
Aphasia (any problem
with
speech)
Visual field (MAND)
Stroke severity
(NIHSS)
Stroke severity
(NIHSS)
Gender
Mood (symptom
checklist)
Depression (‘feeling
sad’)
(Continues)
Physiother. Res. Int. (2015) © 2015 The Authors Physiotheraphy Research International Published by John Wiley & Sons Ltd.
R. Allison et al.
The Profoundly Affected Arm After Stroke
Table 2. (Continued)
Outcome measures
Predictors of impairment which were assessed
Pain
Neurologist assessed the
cause (MAND)
Paci et al., 2007
Pong et al., 2012
Poulin de Courval et al., 1990
Rajaratnam et al., 2007
Ratnasabapathy et al., 2003
Roosink et al., 2011
Sackley et al., 2008
Suethanapornkul and
Kuptniratsaikul, 2008
Wanklyn et al., 1996
Zorowitz et al., 1996
Contracture
Sackley et al. 2008
Ada et al. 2006
Kwah et al., 2012
Malhotra et al., 2011
Pandyan et al., 2003
Pain-dichotomous response
to pain at rest/ on mvt
Pain-VAS
Pain- reported during
physical examination
Pain- numerical rating scale
Pain- questionnaire
designed by study team
Pain-numerical rating scale
at rest & on movement
Pain- reported during
physical examination
Pain- MAND
Pain- questionnaire
designed by study team
Pain- VAS
30% reduction in ROM
(MAND)
ROM at elbow (measured
from photograph- MAND)
Torque-controlled ROM at
elbow wrist and ankle
All other joints- 4 point
scale of movement
restriction
ROM at wrist with
standardized force
ROM wrist (goniometry
with standard force)
Alcohol intake (no. of
drinks)
Global function (mRS)
Shoulder subluxation
(palpation)
Motor control (BMR)
Spasticity (AS)
NA
Smoker
Previous exercise
Motor control
(FMMA)
ROM (goniometer)
Pain
Sensation (MAND)
Subluxation (MAND)
Motor control
(Brunnstrom)
Mood (HADS)
Cognition (Thai
mental state exam)
Stroke severity
(NIHSS)
Pain (NRS)
Motor control (Mot
Ass Scale)
Strength (Manual
muscle test)
NA
NA
NA
NA
Global function (BI)
Spasticity (MAS)
Proprioception (MAND)
NA
NA
NA
NA
Spasticity (Tardieu)
Arm function (ARAT)
Weakness (grip
dynamometer)
MAND = method of assessment not described; ARAT = action research arm test; AS = Ashworth scale; BMRC = British medical research council;
BI = Barthel Index; BL = Birgitte Lindmark Motor Assessment; BMR = Brunnstrom motor recovery; FMMA = Fugl–Meyer motor assessment;
FTT = Find the thumb; HADS = Hospital anxiety and depression scale; LT = light touch; MAS = Modified Ashworth Scale; Mod BI = Modified
Barthel Index; MMSE = mini mental state exam; Mot Ass Scale = Motor assessment scale; mRS = Modified Rankin Score; MST = muscle strength
test; NSAS = Nottingham Sensory Assessment Scale; NIHSS = National Institutes for Health Stroke Scale; ROM = range of movement;
ssNIHSS = sub-scale of NIHSS; UEMI = Upper extremity motor index; VAS = visual analogue scale.
after stroke, five considered contracture and 22 examined pain.
Spasticity was most frequently measured with the
Ashworth Scale, the Modified Ashworth Scale or Tone
Assessment Scale, all of which grade the resistance to
passive movement. Contracture was measured with a
variety of methods including goniometry and
photography, but not all studies described the methods
used. Of the studies that examined pain, nine used a visual analogue or numerical scales, and one used a dichotomous variable (pain was either present or absent
at rest or on movement). The remaining studies of pain
either used unvalidated tools or did not stipulate the
methods of its measure.
Physiother. Res. Int. (2015) © 2015 The Authors Physiotheraphy Research International Published by John Wiley & Sons Ltd.
R. Allison et al.
Predictor measures
The studies examined a wide range of predictor variables including motor and sensory impairment, inattention, cognition, mood, global function and stroke
severity (Table 2). Some used predictor measures that
have well-established validity and reliability such as
the Barthel Index, while other studies developed their
own means of assessing predictors often without reference to psychometric testing.
Study designs
Characteristics of the study designs are summarized in
Table 1. Twenty-eight of the studies were longitudinal
and six were cross-sectional. All of the studies, with
the exception of Pandyan et al. (2003) and Sackley
et al. (2008), identified a single primary measure of a
specific impairment after stroke and reported its incidence. Although a number of studies referred to evaluation of predictors of impairment, this term was
interpreted in two different ways. Some studies
followed a process where clinical tests were conducted
at an early time point to then look at impact of these
early predictors on disability or impairment in the
longer term (for example, whether Barthel score at
7 days post-stroke predicted longer-term degree of
spasticity). The remaining studies looked at the correlation between the selected outcome and related
impairment at a single time point (for example,
whether range of movement at a joint was correlated
with pain). For this review, we included results that related only to early predictors and excluded reference to
correlated impairments. A range of statistical analysis
was used in the studies including univariate analyses,
logistic regression and dividing participants into
groups with specific impairments for comparison. In
the synthesis of results, account was taken only of data
related to incidence, change over time and evaluation
of early predictors as these relate to the original research question.
Quality assessment and risk of bias within
studies
Inter-rater agreement across reviewers for judging the
quality of the studies was good with a kappa coefficient
of 0.65 (Altman 1991). The areas of potential risk of bias
identified in each of the studies are presented in Table 3.
Methodological details reported in the papers were of
The Profoundly Affected Arm After Stroke
variable quality. Most of the studies described selection
criteria, but many restricted recruitment. The most
common shortcomings related to inadequate assessor
blinding (detection bias) (if comparing outcomes to
predictors measures), and the use of unreliable or
unvalidated data collection tools (performance bias).
For example, three of the studies that considered pain
did not state a consistent approach to its measurement
(Cheng et al., 1995; Aras et al., 2004; Suethanapornkul
and Kuptniratsaikul, 2008). A further nine used either
visual analogue scales or numerical rating scales, and although these may be considered the best tools available,
Price et al. (1999) demonstrated that people with stroke
are often unable to accurately complete them. Given
this, and the lack of formal protocol for assessing pain
in the majority of studies, the measurement of this outcome is a potential area of bias in all of the studies that
examined pain. Equally, there is some debate about
whether the measures used to record spasticity, such
as the Ashworth scale differentiate between the neural
and muscular components of resistance, and studies of
reliability and validity have shown mixed results
(Fleuren et al., 2010). Nonetheless, they are widely used
in both clinical practice and research trials.
Results of individual studies
Summary results of individual studies are presented in
Tables 4, 5 and 6. For ease of interpretation, results are
presented for distinct impairments and have been subgrouped into studies that recruited populations of all
people with stroke against those who recruited only
people with stroke who also had hemiplegia or
weakness.
Synthesis of results
There were no studies that evaluated the natural course
of development or potential predictors of difficulty caring for the arm after stroke in a systematic way. Three
studies mentioned difficulty with hygiene and dressing
(Lundstrom et al., 2008; Kong et al., 2010; Lundström
et al., 2010). However, reference to these difficulties
was included within qualitative interviews with an
overall rating of difficulty with care, active function
and mobility, so it was not possible to extract data related to passive care of the arm. Therefore, the synthesis only considered studies that had examined the
related impairments of pain, spasticity and contracture.
Physiother. Res. Int. (2015) © 2015 The Authors Physiotheraphy Research International Published by John Wiley & Sons Ltd.
R. Allison et al.
The Profoundly Affected Arm After Stroke
Table 3. Potential risk of bias in included studies (positive response indicates less risk of bias)
Is sample
Are
Are data
Are
Were participants
Was statistical
representative of assessors
collection tools
withdrawals
unlikely to receive an
analysis
target population? blinded? reliable and valid?
reported?
unintended intervention? appropriate?
Appelros, 2006
Ada et al., 2006
Aras et al., 2004
Bohannon 1988
Cheng et al., 1995
De Jong et al., 2011
Gamble et al. 2002
Gamble et al., 2000
Hadianfard and Hadianfard, 2008
Kong et al., 2012
Kong et al., 2010
van Kujik et al., 2007
Kuptniratsaikul et al., 2013
Kwah et al., 2012
Leathley et al., 2004
Lindgren et al., 2012
Lindgren et al., 2007
Lundstrom et al., 2010
Lundstrom et al., 2009
Lundstrom et al., 2008
Malhotra et al., 2011
Moura et al. 2009
O’Donnell et al., 2013
Paci et al., 2007
Pandyan et al., 2003
Picelli et al., 2013
Pong et al., 2012
Poulin de Courval et al., 1990
Rajaratnam et al., 2007
Ratnasabapathy et al., 2003
Roosink et al., 2011
Sackley et al. 2008
Sommerfeld and Welmer, 2012
Sommerfeld et al., 2004
Suethanapornkul et al., 2008
Urban et al., 2010
Wanklyn et al., 1996
Watkins et al., 2002
Zorowitz et al. 1996
Yes
Yes
No
Yes
No
No
Yes
Yes
Yes
No
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
No
No
No
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
Because of the variation in reporting of data (most
studies reported p values for predictors in isolation of
other statistics), and heterogeneity of the included
studies, a decision was made not to attempt meta-analysis of the data. Therefore, the synthesis is narrative.
a. Difficulty caring for the arm
There were no studies that evaluated the natural
course of development or potential predictors of
difficulty caring for the arm after stroke in a systematic way, although three studies mentioned
No
No
No
No
No
Yes
No
No
No
Yes
No
Yes
No
Yes
Yes
No
No
Yes
No
Yes
Yes
No
No
Yes
Yes
Yes
No
No
No
No
No
No
Yes
Yes
No
Yes
No
Yes
No
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
No
No
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
Yes
No
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
difficulty with hygiene and dressing in a broader
context. Kong, Chua et al. (2010) included interviews with people with stroke or their carers and
identified ‘symptomatic spasticity’ as occurring
when people reported difficulty with passive function, active function, pain or associated reactions.
Lundström et al. (2010) and Lundstrom et al.
(2008) defined ‘disabling spasticity’ as that which
affected any movement, function or social experience and identified this from interviews and unstructured examinations. In all of these studies,
Physiother. Res. Int. (2015) © 2015 The Authors Physiotheraphy Research International Published by John Wiley & Sons Ltd.
R. Allison et al.
The Profoundly Affected Arm After Stroke
Table 4. Studies of spasticity: individual results
Study
Incidence of impairment
Reporting of change over time
Studies which recruited a general population of people post stroke
Kuptniratsaikul et al., 2013
18% at 12 months
Not examined
Leathley et al., 2004
36% at 12 months
Not examined
Not examined
1. Any degree of spasticity predicted by
↓ global function (p < 0.001)
weakness (p < 0.001)
2. Severe spasticity predicted by:
↓ global function (p < 0.001)
Right sided stroke (p < 0.02)
3. No relationship with higher cortical
dysfunction, gender, diabetes and pre-morbid
function
1. Spasticity predicted by
weakness (OR = 10: 95% CI: 2.1–48.4)
stroke severity (p = 0.002)
2. No relationship with sensation or global
disability
Not examined
Watkins et al., 2002
Severe spasticity in 20% at
12 months
Lundstrom et al., 2010
4% at up to 10 days, 27% at
1 month; 23% at 6 months
Not examined
Lundstrom et al., 2008
17% at 1 year
6% had ‘disabling’ spasticity
in the arm
26% at final timepoint
Not examined
20% at 1 week, 18% at
3 months
Prevalence decreased over
time
Moura et al., 2009
Sommerfeld et al., 2004
Not examined
Studies which recruited a population of people post stroke with hemiplegia or weakness
De Jong et al., 2011
10% at 48 hours, 20% at
Some cases resolved at each
10 days, 42% at 3 months and
time point with 1 new case at
42% at 6 months
6 months
Kong et al., 2012
33% at 3 months, 43% at
Some cases resolved at
6 months and 47% at 1 year
12 months, with some new
Severe spasticity in 17%
cases at 6 and 12 months
Kong et al., 2010
van Kujik et al., 2007
78%, severe in 38%
63% at any time point
55% at 26 weeks
Pandyan et al., 2003
Not reported
Picelli et al., 2013
44% had severe spasticity at
6 months
43%
16% had severe spasticity
Urban et al., 2010
Not examined
Spasticity evident in 1 week,
some cases resolved over all
timepoints and few new cases
at 26 weeks
Spasticity evident in 1 week,
and developed over 32 weeks
Not examined
Not examined
difficulties with passive care were included within
qualitative interviews, which also involved active
function and mobility, so it was not possible to extract data related only to passive care of the arm. It
Value of predictors
1. Spasticity predicted by
pain (p < 0.0001; OR = 107.0; 95% CI: 13.5–
847.3),
weakness (p < 0.0001; OR = 91.9; 95% CI:
12.0–699.4)
2. No relationship with gender or age
Not examined
Spasticity predicted by
↓ motor control (p < 0.001)
1. Moderate to severe spasticity predicted by:
↓ global function (p < 0.001)
↓ motor control (p < 0.001)
stroke severity (p < 0.001)
2. No relationship with sensation
Not examined
No relationship between spasticity and arm
control, global function, sensation, apraxia or
Inattention
Spasticity predicted by
↓arm function (p < 0.01)
Spasticity predicted by:
↓ motor control (OR = 0.45 95% CI 0.31–0.65)
Spasticity predicted by
weakness (p < 0.001)
↓sensation (p < 0.001)
is interesting to note that all of these studies aligned
difficulty with passive care within the construct of
‘spasticity’, although a clear correlation between
these constructs has not been established.
Physiother. Res. Int. (2015) © 2015 The Authors Physiotheraphy Research International Published by John Wiley & Sons Ltd.
R. Allison et al.
The Profoundly Affected Arm After Stroke
Table 5. Studies of pain: individual results
Study
Incidence of
impairment
Reporting of
change over time
Value of
predictors
Studies which recruited a general population of people post stroke
Appelros, 2006
11% reported any pain at Not examined
1 year
Gamble et al. 2002
Gamble et al., 2000
Hadianfard et al., 2008
25% developed shoulder
pain at 2 weeks; 40%
developed shoulder pain
within 6 months
32% reported shoulder
pain within first year
Pain predicted by:
stroke severity (OR = 1.24 95% CI: 1.11–1.39)
weakness (OR 1.8 95% CI: 1.3–2.7)
↓sensation (OR 3.2 95% CI: 1.5–6.5)
80% of cases had resolved Shoulder pain predicted by
at 6 months
↓sensation (p < 0.001)
weakness (p < 0.001)
No relationship with depression or global function
6% reported shoulder pain Shoulder pain predicted by
in first 2 months, 12%
within 4 months and 11%
within 6 months
Occasional case reported
↓sensation (p < 0.0001)
after 6 months
aphasia (p < 0.0001)
↓ global function (p < 0.0001)
depression (p < 0.001)
↓motivation (p < 0.0001)
No relationship with visual field deficit
Not examined
Not examined
Kuptniratsaikul et al., 2013 34% reported shoulder
pain at 12 months
Few new cases at
Lindgren et al., 2012
22% reported shoulder
16 months but resolved
pain within 4 months;
72% of these still had pain cases at all timepoints
at 16 months
Lindgren et al., 2007
Lundstrom et al., 2009
O’Donnell et al., 2013
21% report stroke pain at Not examined
1 year
10.6% report chronic pain Not examined
Rajaratnam et al., 2007
22% reported shoulder
pain within 1 week
Ratnasabapathy et al., 2003 17% at 1 week, 20% at
1 month, 23% reported
shoulder pain at 6 months
Sommerfeld et al., 2012
17% initially, 21% at
3 months, 17% at
18 months
Not examined
Suethanapornkul and
Kuptniratsaikul, 2008
Pain resolved in 77% of
cases
19% developed shoulder
pain
Pain presented within
1 week, 72% of cases had
resolved at 6 months
Shoulder pain predicted by
stroke severity (p = 0.008)
left hemiplegia (p = 0.01)
Not examined
Chronic pain predicted by:
Stroke severity (OR = 1.07 95% CI: 1.05–1.09)
Previous depression (OR = 1.67 95% CI: 1.47–1.89)
Previous alcohol intake (OR = 1.37 95% CI: 1.11–1.7)
Diabetes mellitus (OR = 1.18 95% CI: 1.05–1.33)
Peripheral vascular disease (OR = 1.44 95% CI: 1.09–1.91)
Female sex
Statin use
Not examined
Not examined
Pain predicted by
↓sensation (p < 0.05)
↓mobility (p < 0.05)
No relationship with spasticity, motor control or global
function
Pain predicted by:
Shoulder subluxation (OR 2.06 95% CI: 1.08–3.95)
No relationship with motor control, spasticity,
proprioception, cognition, global function or mood
Physiother. Res. Int. (2015) © 2015 The Authors Physiotheraphy Research International Published by John Wiley & Sons Ltd.
R. Allison et al.
The Profoundly Affected Arm After Stroke
Table 6. Studies of contracture: individual results
Study
Areas of bias
quality score
(lower score = increased
risk of bias)
Incidence of
impairment
Reporting change
over time
Studies which recruited a population of people post stroke with hemiplegia or severe stroke
Ada et al., 2006
3/6
51% of those with hemiplegia Contracture evident by
developed contracture
2 weeks and plateaued by
9 weeks
Kwah et al., 2012
5/6
52% develop contracture
Not examined
Malhotra et al., 2011
5/6
100% of those without
function develop contracture
Pandyan et al., 2003
4/6
Not reported
Sackley et al., 2008
3/6
43% had contracture at
3 months, 56% at 6 months
and 67% at 12 months
b. Spasticity
Incidence
In studies that examined general populations of people post-stroke, spasticity in muscles of the arm was
present in 18% of participants at 3 months
(Sommerfeld et al., 2004) and 17% at 1 year
(Lundstrom et al., 2008). Populations of people
who originally presented with weakness had a higher
incidence of spasticity with rates between 33% at
3 months (Kong et al., 2012) and 78% at 12 months
(Kong et al., 2010).
Time course
Spasticity was evident in some participants as early
as 48 hours post-stroke (De Jong et al., 2011). Although the course of spasticity was fairly dynamic,
for the majority of cases, it was evident in most participants who would experience it by 3 months (van
Kuijk et al., 2007) and developed over at least
32 weeks (Pandyan et al., 2003). There were some
cases where early spasticity resolved.
Risk factors
The most frequent predictors of risk of spasticity were
weakness (Lundström et al., 2010; Moura et al., 2009;
Urban, Wolf et al. 2010; Leathley et al., 2004) and
Contracture evident by
6 weeks and plateaued by
24 weeks
Contracture evident by
6–8 weeks and developed over
32 weeks
Not examined
Value of
predictors
Not examined
Contracture predicted by
stroke severity (p < 0.01)
weakness (p < 0.01)
↓motor function (p < 0.01)
No relationship with pain or
spasticity
Contracture predicted by:
↓function (p < 0.01)
Contracture predicted by
Weakness (p < 0.01)
Not examined
reduced motor control (Kong et al., 2012; De Jong
et al., 2011; Pandyan et al., 2003). Stroke severity
(Kong et al., 2012; Lundström et al., 2010) and reduced global function (Leathley et al., 2004; Kong
et al., 2012) were also positive predictors of risk in
at least two studies. The impact of sensory loss on
spasticity risk is not clear, with one study identifying
a positive relationship (Urban, Wolf et al., 2010) and
three discounting this (van Kuijk et al., 2007;
Lundström et al., 2010; Kong et al., 2012). However,
most of these studies did not clearly identify how
sensation was quantified, making comparison difficult. Moura et al. (2009) identified early reports of
pain as a predictor of risk of spasticity, but in this
study, a significant number of areas of potential bias
were identified on the quality assessment tool.
Higher cerebral dysfunction including apraxia and
inattention does not appear to increase risk (Leathley
et al., 2004; van Kuijk et al., 2007).
c. Pain
Incidence
Pain in any part of the body was reported by 10%
(O’Donnell et al., 2013) to 21% of participants
Physiother. Res. Int. (2015) © 2015 The Authors Physiotheraphy Research International Published by John Wiley & Sons Ltd.
R. Allison et al.
The Profoundly Affected Arm After Stroke
(Sommerfeld and Welmer, 2012) from a general
population of people recovering from stroke, and incidence of shoulder pain occurred in 19%
(Suethanapornkul and Kuptniratsaikul, 2008) to
40% (Gamble et al., 2002). Higher incidences of
shoulder pain were found in studies of people with
hemiplegia, or who were receiving rehabilitation.
Within this population, incidence varied from 22%
(Roosink et al., 2011) to 90% (Bohannon, 1988).
Time course
Pain was reported as early as 1 week post-stroke
(Ratnasabapathy et al., 2003), with new cases of pain
still being reported at up to 16 months post-stroke
(Lindgren et al., 2007). The highest incidence appeared to be within the first 6 months post-stroke
(Wanklyn et al., 1996; Hadianfard and Hadianfard,
2008). The course of pain was fairly dynamic, with
some participants reporting resolution of pain at all
time points over the first year post-stroke (Wanklyn
et al., 1996; Lindgren et al., 2007). However, one
study found that 72% of people who experience
shoulder pain at 4 months still had pain at
16 months (Lindgren et al., 2012).
Risk factors
The most common predictor of increased risk of pain
was reduced sensation (Gamble et al., 2000;
Appelros, 2006; Hadianfard and Hadianfard 2008;
Sommerfeld and Welmer, 2012), with shoulder subluxation (Paci et al., 2007; Suethanapornkul and
Kuptniratsaikul, 2008), weakness (Gamble et al.,
2000; Appelros, 2006) and stroke severity (Appelros
2006; Lindgren et al., 2007; O’Donnell et al., 2013)
also identified as potential risk factors. The significance of depression was not clear, with two studies
identifying a positive link with pain (Hadianfard
and Hadianfard, 2008; O’Donnell et al., 2013), and
two discounting this (Gamble et al., 2002; Kong
et al., 2012). Equally, reduced global function was a
predictor of pain in one study (Hadianfard and
Hadianfard, 2008), but did not predict pain in two
others (Gamble et al., 2002; Sommerfeld and
Welmer, 2012). Aphasia and reduced motivation
(Hadianfard and Hadianfard, 2008), and reduced
mobility (Sommerfeld et al., 2004), had some predictive value in one study each. However, reduced motor control (Suethanapornkul and Kuptniratsaikul,
2008; Sommerfeld and Welmer, 2012), spasticity,
proprioception and cognition (Suethanapornkul
and Kuptniratsaikul, 2008) and visual field loss
(Hadianfard and Hadianfard, 2008) were not associated with increased risk of pain.
d. Contracture
Incidence
In a single study of a general population of stroke
survivors, 52% of participants developed at least
one contracture, with the most common joint affected being the shoulder (25%) and elbow (22%)
(Kwah et al., 2012). In those with hemiplegia or severe stroke, 51% of participants had elbow contracture (Ada et al., 2006).
Time course
Contracture was detected within 2 weeks of stroke
(Ada et al., 2006) and continued up to 32 weeks
(Pandyan et al., 2003), although only one study examined this time point.
Risk factors
Contracture was most frequently predicted by weakness (Pandyan et al., 2003; Kwah et al., 2012) and reduced motor function (Malhotra et al., 2011; Kwah
et al., 2012). It was linked with increased stroke
severity but not degree of spasticity or pain (Kwah
et al., 2012).
Discussion
The purpose of this review was to identify the incidence
and natural course of pain, spasticity, contracture and
difficulty with passive care in the profoundly affected
arm and to identify potential predictors of difficulty
caring for the arm or these related impairments.
To date, there appear to be no studies that specifically examine the construct of difficulty caring for the
profoundly affected arm after stroke. Although three
of the studies identified in this review referred to difficulty with care of the arm (Lundstrom et al., 2008;
Kong et al., 2010; Lundström et al., 2010), this was included within the construct of problematic spasticity
and was identified in interviews and examinations
along with difficulties with active function, pain and
mobility. It was therefore not possible to identify the
incidence or time course of difficulties caring for the
arm as a discrete construct, or identify potential predictors of this problem. There is increasing recognition
Physiother. Res. Int. (2015) © 2015 The Authors Physiotheraphy Research International Published by John Wiley & Sons Ltd.
R. Allison et al.
that in clinical practice, goals concerning the delivery of
care to the arm are relevant, so future research in rehabilitation will need to examine this concept in detail.
Therefore, all of the studies included in this review
focused on the impairments of spasticity, pain and contracture, which have been identified as having an association with difficulty caring for the arm. Risk of bias
was fairly significant in most of the studies identified,
particularly concerning the assessment tools used for
quantifying both predictors and outcomes. Some studies included self-developed tools with no reference to
psychometric testing, but even those using recognized
tools had some risk of bias, as many accepted tools still
have limited validity and reliability (Hobart et al.,
2007). Therefore, caution should be applied in drawing
conclusions from the analysis.
There were higher incidences of pain, spasticity and
contracture in people who originally presented with
hemiplegia after stroke when compared with general
populations of people recovering from stroke. In those
with hemiplegia, the incidence of arm spasticity ranged
from 33% to 78%, shoulder pain affected 22% to 90%
and arm contracture was present in at least 50%. The
incidence of both contracture and pain in the arm after
stroke appears to be similar to that experienced by people following brain injury, where incidences of contracture between 44% (Yarkony and Sahgal 1987) and 84%
(Moseley et al., 2008) and incidences of pain between
52% and 58% (Lahz and Bryant 1996) have been
identified.
Spasticity and pain were detected from as early as
1 week after stroke, with contracture apparent by
2 weeks. Many cases were dynamic in presentation,
with spasticity and contracture continuing to develop
beyond 3 months post-stroke and pain developing
within 6 months of stroke. Therefore, clinicians may
need not only to intervene early post-stroke but also
to be prepared to act over a longer time period in managing disability. As interventions are developed, they
will also need to take account of the longer-term evolution of these impairments.
Evaluation of the potential predictors of increased
risk of impairment is limited, as many of the tools for
quantifying the predictors were of limited quality.
However, the most consistent risk factors for developing spasticity and contracture were weakness and reduced motor control, and the risk of pain is most
commonly predicted by reduced sensation, shoulder
subluxation, weakness and stroke severity. It is less
The Profoundly Affected Arm After Stroke
clear if there is a relationship with higher cerebral functions and depression.
Limitations of the review
A comprehensive literature search was undertaken as
part of this review, but may be subject to retrieval bias.
Notable omissions include the grey literature such as
reports, conference proceedings and theses outside
commercial publications and articles not published in
English. In those studies that have been included, there
are large variations within the populations of people
with stroke studied, making synthesis of the results
limited. Many of the studies themselves used data collection tools that may either not have been subjected
to psychometric testing or, if they had, may still not
be reliable in people with stroke with particular difficulties such as aphasia or inattention, adding further
potential bias.
Implications for physiotherapy practice
There is currently no evidence to predict the risk of developing difficulty caring for the profoundly affected
arm after stroke. However, related impairments such
as spasticity, contracture and pain affect a significant
number of survivors and can start developing within
1–2 weeks of stroke and may not stabilize for at least
6 months post-stroke.
There is no sufficient evidence for clinicians to develop targeted interventions at this stage. However,
the research available suggests that clinicians may
need not only to intervene early post-stroke but also
to be prepared to act over a longer time period in
managing disability. Further research is required to establish the relationship between impairments and difficulty caring for the arm and to investigate if
predictors of impairment can be used to identify those
at risk of developing difficulty caring for the arm. This
review has informed the design of a longitudinal study
Care of the Arm after Stroke to test a range of predictors of difficulty caring for the arm and to develop a
profile of impairment in people with profoundly affected arm.
Ethical approval
No ethical approval was required.
Physiother. Res. Int. (2015) © 2015 The Authors Physiotheraphy Research International Published by John Wiley & Sons Ltd.
The Profoundly Affected Arm After Stroke
Acknowledgements
The authors are grateful to Jacky Youngman for her assistance with obtaining articles for inclusion in the
review.
There was no external funding for this project.
Conflict of interest
The authors report no declarations of interest.
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